- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.34 / $1,154.34 / $1,203.65
| Professional | | $1,154.34 | $1,154.34 | $1,203.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.04 / $959.02 / $1,420.30
| Professional | | $747.04 | $959.02 | $1,420.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.81 / $1,005.81 / $1,005.81
| Facility | | $1,005.81 | $1,005.81 | $1,005.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.59 / $1,342.46 / $1,606.82
| Professional | | $919.59 | $1,342.46 | $1,606.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.50 / $1,059.23 / $1,624.92
| Professional | | $915.50 | $1,059.23 | $1,624.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.34 / $1,154.34 / $1,154.34
| Professional | | $1,154.34 | $1,154.34 | $1,154.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,561.46 / $4,561.46 / $4,561.46
| Facility | | $4,561.46 | $4,561.46 | $4,561.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.94 / $1,050.53 / $1,358.44
| Professional | | $724.94 | $1,050.53 | $1,358.44 |